The Second Other Provider ID is missing or invalid. Valid Numbers Are Important For DUR Purposes. Principal Diagnosis 6 Not Applicable To Members Sex. Normal delivery payment includes the induction of labor. Invalid Procedure Code For Dx Indicated. Training Completion Date Must Be Within A Year Of The CNAs Certification, Test, Date. Incorrect Liability Start/end Dates Or Dollar Amounts Must Be Corrected Through County Social Services Agency Before Claim/Adjustment/Reconsideration RequestCan be Processed. Allowed Amount On Detail Paid By WWWP. Denials with solutions in Medical Billing; Denials Management - Causes of denials and solution in medical billing; Medical Coding denials with solutions Claim Corrected. Prosthodontic Services Appear To Have Started After Member EligibilityLapsed. Transplants and transplant-related services are not covered under the Basic Plan. Denied. If you have questions regarding your remittance advice, please contact our Provider Call Center at 1-888-FIDELIS (1-888-343-3547) or your . The Service Requested Does Not Correspond With Age Criteria. The Resident Or CNAs Name Is Missing. Amount Recouped For Duplicate Payment on a Previous Claim. The Clinical Profile/Diagnosis Makes This Member Ineligible For AODA Services. Claim or line denied. that provide either supplemental explanation for a monetary adjustment or policy information are required in the remittance advice transaction. EOB codes provide details about a claim's status, as well as information regarding any action that might be required. Crosswalk - Adjustment Reason Codes and Remittance Advice (RA) Remark Codes to PHC Explanation (EX) Codes Revised 11/16/2020 Page 1 Key: If RA has . Recd Beyond 90 Days Special Filing Deadline FOr System Generated Adjmts/Medicare X-overs/Other Insurance Reconsideration/Cou rt Order/Fair Hearing. Resubmit the Claim with the Appropriate Modifier for Provider Type andSpecialty. Number Is Missing Or Incorrect. Tooth number or letter is not valid with the procedure code for the Date Of Service(DOS). Tooth surface is invalid or not indicated. Denied. Once Therapy Is Prior Authorized, All Therapy Must Be Billed With A Valid Prior Authorization Number. One or more Diagnosis Code(s) in positions 10 through 25 is not on file. Explanation of benefits. Additional rental of a negative pressure wound therapy pump is limited to 90 days in a 12 month period. Header From Date Of Service(DOS) is after the date of receipt of the claim. We have created a list of EOB reason codes for the help of people who are . Other Medicare Part A Response not received within 120 days for provider basedbill. Detail To Date Of Service(DOS) is required. Denied. This National Drug Code (NDC) requires a whole number for the Quantity Billed. Was Unable To Process This Request Due To Illegible Information. Denied. Provider Reminders: Claims Definitions. NDC- National Drug Code is restricted by member age. A valid Referring Provider ID is required. Denied. The Total Number Of Sessions Requested Exceeds Quarterly Guidelines. The Hearing Aid Recommended Is Not Necessary; The Member Could Be Adequately Fitted With A Conventional Aid. BMN prior authorization may be submitted for Mental Health drugs for which a Core Plan transitioned member has been previously grandfathered. This HMO Capitation Payment Is Being Recouped It Was Inappropriately Paid During The Inital February HMO Capitation Cycle. Missing Or Invalid Level Of Effort And/or Reason For Service Code, Professional Service Code, Result Of Service Code Billed In Error. Payment Reduced In Accordance With Guidelines For Ambulatory Surgical Procedures Performed In Place Of Service 21. Laboratory Is Not Certified To Perform The Procedure Billed. Denied. Pricing Adjustment/ The submitted charge exceeds the allowed charge. One or more Occurrence Code Date(s) is invalid in positions nine through 24. Procedure Code is restricted by member age. We Are Recouping The Payment. Inpatient psychiatric services are not reimbursable for members age 21 65 (age 22 if receiving services prior to 21st birthday). Please Request Prior Authorization For Additional Days. Please Indicate One Prior Authorization Number Per Claim. Adequate Justification For Starting Member In AODA Day Treatment Prior To Authorization being Obtained Has Not Been Provided. Auditory Screening with Preventive Medicine Visits. Seventh Occurrence Code Date is required. Has Already Issued A Payment To Your NF For This Level L Screen. SMV Or Prescribing Provider Description Code(s) Missing OrInvalid. The revenue accomodation billing code on the claim does not match the revenue accomodation billing code on the member file or does not match for these dates of service. Services Not Allowed For Your Provider T. The Procedure Code has Place of Service restrictions. Please Correct And Resubmit. Incorrect Or Invalid National Drug Code Billed. Please Obtain A Valid Number For Future Use. The detail From Date Of Service(DOS) is after the detail To Date Of Service(DOS). Claim paid at the program allowed amount. Schedule 3, 4 or 5 drugs are limited to the original dispensing plus 5 refillsor 6 months. Request Denied Due To Late Billing. The sum of all Value Code amounts must be numeric and less than or equal to 999.999.999. As a result, providers experience more continuity and claim denials are easier to understand. Pricing Adjustment/ Prescription reduction applied. The Second Occurrence Code Date is invalid. Resubmit With All Appropriate Diagnoses Or Use Correct HCPCS Code. Service Denied. Please Correct And Resubmit. Denied. This Claim Cannot Be Processed. This level not only validates the code sets , but also ensures the usage is appropriate for any Unable To Process Your Adjustment Request due to The Claim Type Of The Adjustment Does Not Match The Claim Type Of The Original Claim. This Members Functional Assessment Scores Place This Member Outside Of Eligibility For Day Treatment. Billing Provider Name Does Not Match The Billing Provider Number. No policy override available for BadgerCare Plus Benchmark Plan, Core Plan or Basic Plan. This service is payable at a frequency of once per 12-month period, per provider, per hearing aid. The Revenue Code is not payable for the Date(s) of Service. Fifth Other Surgical Code Date is invalid. The From Date Of Service(DOS) for the Second Occurrence Span Code is required. Procedure Code 59420 Must Be Used For 5 Or More Prenatal Visits With One Charge. No Rendering Provider Status Found for the From and To Date Of Service(DOS). Modifier Submitted Is Invalid For The Member Age. The Provider Type/specialty Is Not Recognized For These Date(s) Of Service. This service was previously paid under an equivalent Procedure Code. Additional information is needed for unclassified drug HCPCS procedure codes. Copyright 2023 Wellcare Health Plans, Inc. We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions. Pricing Adjustment/ Third party liability amount applied is greater than the amount paid by the program. Effective 04/01/09, the BadgerCare Plus Core Plan will limit coverage for Glucocorticoids-Inhaled to Flovent. CO/204. Please Resubmit A New Adjustment/reconsideration Request Form And Indicate TheMost Recent Cclaim Number Where Payment Was Made Or Allowed. Rqst For An Acute Episode Is Denied. Supervising Nurse Name Or License Number Required. This drug is a Brand Medically Necessary (BMN) drug. EOB Any EOB code that applies to the entire claim (header level) prints here. Please Request A Corrected EOMB Through The Medicare Carrier And Adjust With The Corrected EOMB. Claim Denied/cutback. Multiple Screens Performed Within A Fifteen Day Time Frame For This SSN. Medical record number If a medical record number is used on the provider's claim, that number appears here. This is a same-day claim for bill types 13X, 14X, 71X, or 83X and there are multiple units or combination of chemistry/hemotology tests. Payspan's Core Payment Network comes with a feature that allows payers to send members an electronic version of their Explanation of Benefits (eEOB). Healthcheck screenings or outreach limited to three per year for members between the age of one and two years. The sum of the Medicare paid, deductible(s), coinsurance, copayment and psychiatric reduction amounts does not equal the Medicare allowed amount. Revenue code submitted with the total charge not equal to the rate times number of units. You can choose to receive only your EOBs online, eliminating the paper . Revenue code 082X is present on an ESRD claim which also contains revenue code088X (X frequency non equal to 9). Timely Filing Deadline Exceeded. Continuous home care must be billed in an hourly quantity equal to or greater than eight hours, up to and including 24 hours. A National Provider Identifier (NPI) is required for the Performing Provider listed in the header. Denial Codes. Reference: Transmittal 477, change request 3720 issued February 18, 2005. Billing Provider is not certified for the Date(s) of Service. Admission Denied In Accordance With Pre-admission Review Criteria. Intermittent Peritoneal Dialysis hours must be entered for this revenue code. This Is Not A Good Faith Claim. Contact The Nursing Home. Level, Intensity Or Extent Of Service(s) Requested Has Been Modified Consistent With Medical Need As Defined In The Plan Of Care. Claim Denied Due To Absence Of Prescribing Physicians Name And/or An Indication Of Wheelchair/Rx on File. Medical Billing and Coding Information Guide. Denied due to The Member WCDP Id Number Is Incorrect Or Not On Our Current Eligibility File. Billed amount exceeds prior authorized amount. Either The Date Was Not In MM/DD/CCYY Format Or Its AFuture Date. Please Clarify. Correction Made Per Medical Consultant Review. The National Drug Code (NDC) is not on file for the Dispense Date Of Service(DOS). Personal care subsequent and/or follow up visits limited to seven per Date Of Service(DOS) per member. Therefore, physician provider claim would deny. The Members Gait Is Not Functional And Cannot Be Carried Over To Nursing. Service(s) exceeds four hour per day prolonged/critical care policy. Effective July 15, 2021 through December 31, 2021: Temporary Relaxation of Prior Authorization . An Alert willbe posted to the portal on how to resubmit. Refer To Provider Handbook. By continuing to use our site, you agree to our Privacy Policy and Terms of Use.
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